Central hepatectomy

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. Subcutaneous heparin was given in the preop area. The patient was transported to the operating room and placed on the table in supine position, SCDs applied, preoperative cefoxitin given. The patient was secured to the table with straps and all boney areas padded. General anesthesia was induced and patient was intubated without issue. A foley catheter was inserted.

A small Kocher incision was made big enough to fit a single hand. Palpation of the peritoneal cavity did not reveal any obvious intraperotineal disease. The Kocher incision was widened and the Bookwalter retractor was used. We were met with adhesions from previous laparoscopic cholecystectomy that were lysed with electrosurgical devices for [ ] minutes. There was a thick adhesion and mass on the right mid abdominal wall that was biopsied and sent for frozen pathology that returned negative for malignancy.

We next explored the retropancreatic head space, there was noted to be no anatomic vascular variants, and we dissected and removed two lymph nodes that were sent for permanent pathology. These lymph nodes were soft and not concerning for disease. We encountered venous bleeding from a branch separate from the portal vein that was controlled with a large clip. This area was packed with SurgiFoam. The falciform was divided and made hemostatic with 3-0 silk ties.

Next we turned our attention to the hepatoduodenal ligament which was stripped of it's lymphatic tissue including excision of a lymph node overlying the left gastric artery. No concerning lymph nodes were encountered. Happy with our lymphadenectomy we proceeded with hepatic wedge resection.

A dissection line 2 cm deep to the gallbladder fossa was outlined. A Pringle maneuver was performed and this area of liver was resected with the Harmonic scalpel. Brisk venous bleeding was controlled with figure of eight 3-0 Prolene stitches. The specimen was removed and sent for permanent pathology. The liver edge was made further hemostatic using spray Bovie cautery. The liver edge was inspected and there was noted to be no leakage of bile. The cystic duct margin from the original cholecystectomy was widely free of any disease so additional cystic duct resection was not indicated. SurgiFoam was packed into the resected liver bed. A 10 Fr JP drain was introduced through the right abdomen and placed in the gallbladder fossa.

The fascia was closed with 0 PDS suture in a figure-of-eight fashion at the midline. Then the remainder of the incision was closed by first closing the posterior layer with 0 PDS in a running fashion followed by the anterior layer in the same fashion. The wound was further irrigated and the skin was closed with staples and dressed with a Prevena dressing.

The patient tolerated the procedure well and remained stable. She was liberated from anesthesia and extubated without issue and transported to the surgical intensive care unit in stable condition.